Most arrest patients that arrive in our hospital are intubated pre-hospital by paramedics. The benefits/harm of prehospital intubation can certainly be debated, but that's for another time. The few that aren't intubated were either difficult or had too many other complicating issues and so present with some type of supraglottic device or just a BVM. My approach (as I'm typically the only physician in the room) is to run the code until there's ROSC and at that point establish a definitive airway - if there's no ROSC then I don't feel the need to establish an airway just to pronounce a patient. I was surprised to hear that many residents are taught the need to do so, leading to prolonged pauses in compressions (this is bound to happen even with the best of intentions). It reminded me of my own time in residency and thinking back on it there was always a sense that an airway needed to be established, and there was almost always a pause in compressions to do so. I fail to see the need to establish a definitive airway when a patient's easy to bag and compression effectiveness can be maximized. Others thoughts?

If you can get the tube without pausing compressions, and you have the available staff to perform all other aspects of ACLS, why not? I never stop compressions for intubation, however. I throw in a supraglottic airway if I can't get a tube in.

I typically am doing it for airway protection more than anything else. How many cpr patients have you had vomit all over the place while doing compressions? I can name a handful. If/when you get ROSC, you're gonna have a whole other set of issues when they start inhaling their stomach contents. I don't pause compressions for the tube, ideally line it up and get it in during pulse check. Should take less than 10 sec on your frail nursing home patients without advanced directives who prbly shouldn't be intubated in the first place...

But yeah; I'm like you - I don't establish an airway if there's no ROSC.

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Didn't the AHA change it from A-B-C to C-A-B?

Just glidescope a tube in while doing compressions. Or throw one in during a rhythm/pulse check (though you may have to rely on your best nurse to look at the rhythm ~ or take a quick look at the strip after the tube is in).

If they're already dead, throw a tube in, do 1 more round and then call it. Even though we know it's not right, don't open yourself up to litigation due to upset family members feeling you didn't do "everything" or didn't do a basic airway.

We should clarify that we're discussing adult arrests, which are much more likely to be cardiac in origin. In Peds arrests, the likelihood of a primary respiratory arrest goes up, so the calculus changes.

In adult arrests:
If you're bagging easily via mask or via LMA, focus on getting ROSC. Intubate later.
If you can not ventilate via supraglottic devices, place an ETT during pulse check, but prioritize compressions over plastic.
If you're in an academic center and you're about to call a code, consider extending efforts so that the intern to get a crack at a crash tube...then call the code a few minutes later.

I usually put a tube in towards the end then run it for another round or two just in case. No harm, maybe benefit. And extra intubating practice doesn't hurt. I certainly don't stop early to intubate if I have an LMA or something I can drop.

I like to take out the pre-hospital supraglottic and re intubate if one is in place because I find they are often misplaced.

Side note: I vaguely remember hearing about an RCT comparing pre-hospital airways to supraglottics that is underway.

The biggest question is: are your medics actually good at intubation? Most likely they are not, so if they come in saying it was a difficult airway - take it with a grain of salt. (I say this as a former paramedic.)

We (residency) don't stop compressions for the airway I'm an arrest, and we will at least get a supraglottic in place. I'm likely to continue that after June 30, though may change my mind when I'm single coverage.

Do you guys bag through mask/LMA through compressions? Only seen one non-intubated code in our ED so far and they bagged through compressions... I just kept imagining the stomach getting gigantic but they thought it was better than stopping compressions although BLS teaches the 30:2 ratio.

Do you guys bag through mask/LMA through compressions? Only seen one non-intubated code in our ED so far and they bagged through compressions... I just kept imagining the stomach getting gigantic but they thought it was better than stopping compressions although BLS teaches the 30:2 ratio.

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Compress, compress. You don't want to lose the preload that you have created. Even 10 seconds of no compressions drops the pressure. Asynchronous BVM is fine in this case.

Problem with no airway is, especially when I'm the sole provider, the patient isn't even being bagged appropriately. We're not getting two handed mask seal with appropriate rate of respirations. Someone untrained in airway management (RT/RNs) is standing over the patient with the mask lazily sitting on top of the face bagging 69 times per minute. If I'm going to take over mask seal I might as well establish a better airway.

If I'm totally alone, I'll throw a supraglottic device in place. If more support around, or if anesthesia finally shows up (in the case of floor code) then I'm all for the airway protection and better oxygenation/ventilation, but like I said, I won't allow compressions to be stopped for it.

I typically am doing it for airway protection more than anything else. How many cpr patients have you had vomit all over the place while doing compressions? I can name a handful. If/when you get ROSC, you're gonna have a whole other set of issues when they start inhaling their stomach contents. I don't pause compressions for the tube, ideally line it up and get it in during pulse check. Should take less than 10 sec on your frail nursing home patients without advanced directives who prbly shouldn't be intubated in the first place...

Problem with no airway is, especially when I'm the sole provider, the patient isn't even being bagged appropriately. We're not getting two handed mask seal with appropriate rate of respirations. Someone untrained in airway management (RT/RNs) is standing over the patient with the mask lazily sitting on top of the face bagging 69 times per minute. If I'm going to take over mask seal I might as well establish a better airway.

If I'm totally alone, I'll throw a supraglottic device in place. If more support around, or if anesthesia finally shows up (in the case of floor code) then I'm all for the airway protection and better oxygenation/ventilation, but like I said, I won't allow compressions to be stopped for it.

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Agree with the above.

Continuous CPR is your #1 priority however that's no excuse for not intubating patients. In most patients you should be able to intubate during chest compressions or at least during pulse checks. If you can't get the intubation for whatever reason then just throw in an LMA. As far as needing to intubate these patients in the first place the last thing you want is the patient aspirating all over the place during a code. Any patient with ROSC is going to very hemodynamically unstable initially and they need all the help they can get including having healthy lungs. BVM ventilation is quite frankly horrible when it comes to providing good ventilation and nearly always causes a large amount of gastric insufflation with the potential for aspiration. If anything I would argue against BVM ventilation and instead advocate for placing a LMA right away then intubating once all your equipment is set up and the patient has gotten a full round of CPR. The other thing you guys are forgetting is that is really hard to gat an accurate ETCO2 to guide CPR with BVM ventilation.

I typically am doing it for airway protection more than anything else. How many cpr patients have you had vomit all over the place while doing compressions? I can name a handful. If/when you get ROSC, you're gonna have a whole other set of issues when they start inhaling their stomach contents. I don't pause compressions for the tube, ideally line it up and get it in during pulse check. Should take less than 10 sec on your frail nursing home patients without advanced directives who prbly shouldn't be intubated in the first place...
Sent from my SM-G935V using Tapatalk

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What about the non-frail nursing home patients? The 50 year old obese short-neck patient? The scenario I envision is you think it's gonna be easy, it's not, but now you've started down this road...

Just glidescope a tube in while doing compressions. Or throw one in during a rhythm/pulse check (though you may have to rely on your best nurse to look at the rhythm ~ or take a quick look at the strip after the tube is in).

If they're already dead, throw a tube in, do 1 more round and then call it. Even though we know it's not right, don't open yourself up to litigation due to upset family members feeling you didn't do "everything" or didn't do a basic airway.

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I've never had a family member question the lack of a tube. Most of the time they're inserted prehospital but if not I feel there are enough other things to do (bedside ultrasound to check for tamponade), checking the monitor, feeling for pulse, ensuring good BVM, going down the list of causes of PEA. Establishing a definitive airway just doesn't make the list for me. Not only that, but even with the best of intentions, it's VERY easy to pause for more than 10 seconds

Do you guys bag through mask/LMA through compressions? Only seen one non-intubated code in our ED so far and they bagged through compressions... I just kept imagining the stomach getting gigantic but they thought it was better than stopping compressions although BLS teaches the 30:2 ratio.

One of the bigger issues, even bigger than airway, is how cavalier EMS is about compressions during transfer from the stretcher to the gurney. I mean, half assed one-handed compressions coming in, and then sometimes stopping compressions for 45 seconds while trying to transfer the patient over, taking the board off and all the millions of straps etc. Nothing makes me more irate than watching all the blank faces when compressions are stopped during transferring the patient.

I know the majority of these out of hospital cardiac arrest patients are dead coming through the door, but you can't expect at giving yourself a reasonable chance at ROSC if you are off the chest for even a few seconds. The airway issue doesn't seem to matter if you can't generate enough pressure to pump blood to the lungs in the first place.

southerndoclife is goodModerator EmeritusLifetime Donor10+ Year Member

One of the bigger issues, even bigger than airway, is how cavalier EMS is about compressions during transfer from the stretcher to the gurney. I mean, half assed one-handed compressions coming in, and then sometimes stopping compressions for 45 seconds while trying to transfer the patient over, taking the board off and all the millions of straps etc. Nothing makes me more irate than watching all the blank faces when compressions are stopped during transferring the patient.

I know the majority of these out of hospital cardiac arrest patients are dead coming through the door, but you can't expect at giving yourself a reasonable chance at ROSC if you are off the chest for even a few seconds. The airway issue doesn't seem to matter if you can't generate enough pressure to pump blood to the lungs in the first place.

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Interruptions in CPR can be minimized by ED staff helping EMS crews move the patient over. Even I help move the patient over instead of standing around watching them do it.

I do tube all codes, barring the occasional down x 2 hours with a good LMA in... rare.

I never pause compressions to intubate. I've never felt the need. Especially with the 'ol glidescope around.

I don't necessarily tube as soon as they hit the door. Again, sole-provider ED most of the day, so I take a look at the case and see what is most reasonable regarding their down time, likely mechanism, other procedures that need to be done.

I certainly have had a couple cases that sounded like respiratory/hypoxic arrests who got ROSC immediately after intubation and 100% Fi02. Never know if that was the answer, but it seemed so at the time. For likely cardiac/Vfib arrests, there is some thought that intubation with positive pressure ventilation will decrease your preload/venous return and make ROSC more difficult. I often let these go a round or two without intubating, depending on pre-hospital timeline...

I do tube all codes, barring the occasional down x 2 hours with a good LMA in... rare.

I never pause compressions to intubate. I've never felt the need. Especially with the 'ol glidescope around.

I don't necessarily tube as soon as they hit the door. Again, sole-provider ED most of the day, so I take a look at the case and see what is most reasonable regarding their down time, likely mechanism, other procedures that need to be done.

I certainly have had a couple cases that sounded like respiratory/hypoxic arrests who got ROSC immediately after intubation and 100% Fi02. Never know if that was the answer, but it seemed so at the time. For likely cardiac/Vfib arrests, there is some thought that intubation with positive pressure ventilation will decrease your preload/venous return and make ROSC more difficult. I often let these go a round or two without intubating, depending on pre-hospital timeline...

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Yeah this is my practice too for vast majority of adults.

I definitely wait a few rounds before considering a tube and spend the first few rounds focusing on other things: cpr quality, end tidal on pt, IV access, quick echo, ensuring code status, etc. Added bonus is that you're not cutting their preload off at the knees by avoiding the PPV of intubation.

If you gotta intubate a pt w/ongoing compressions than VL is your best friend and is way easier than DL during compressions IMHO. Don't waste a pulse check on a tube if you don't have to.

To stir the pot a little further, if you're intubating a patient in arrest are you using meds?

If I can intubate them without them gagging while compressions on going, they don't need meds and certainly I can't spare an RN to run to the med room and access the pixis. If its not in the code cart I'm not giving it.

that said I can imaging a case where we are getting some spontaneous movements during compressions (very fresh vfib with high quality immediate CPR). I'd probably just bolus ketamine to make sure they didn't remember anything if we do get the save, and not kill their hemodynamics... haven't personally needed to do that.

I had one guy (STEMI) resume consciousness during compressions multiple times. Pausing for pulsecheck he would go out again. It was awful and weird, and I ended up hitting him with etomidate so he would stop freaking out, but we couldn't get him back. And by freaking out I mean that he was actually yelling and trying to push us away. He died right there with the cath team standing by because they couldn't take him without a pulse. And yes, I intubated him. I, like most of the other commenters, intubate during compressions, and usually not right off the bat, unless I'm pretty sure it was a respiratory-driven arrest - like the guy with an entire chicken breast obstructing his airway. The entire team jumped and shrieked when I yanked it out - which was pretty funny, considering. We got ROSC on that one.

I don't usually use drugs - excepting weird cases like the first one.

While there are case reports of people going to the cath lab without ROSC and ongoing CPR, my shop doesn't have ECMO capability and I doubt any of my interventional cardiologists would go for that.

I remember that guy quite vividly. I suppose there might be some PTSD there... I hate it when they coming in talking and die.

I had one guy (STEMI) resume consciousness during compressions multiple times. Pausing for pulsecheck he would go out again. It was awful and weird, and I ended up hitting him with etomidate so he would stop freaking out, but we couldn't get him back. And by freaking out I mean that he was actually yelling and trying to push us away. He died right there with the cath team standing by because they couldn't take him without a pulse. And yes, I intubated him. I, like most of the other commenters, intubate during compressions, and usually not right off the bat, unless I'm pretty sure it was a respiratory-driven arrest - like the guy with an entire chicken breast obstructing his airway. The entire team jumped and shrieked when I yanked it out - which was pretty funny, considering. We got ROSC on that one.

I don't usually use drugs - excepting weird cases like the first one.

While there are case reports of people going to the cath lab without ROSC and ongoing CPR, my shop doesn't have ECMO capability and I doubt any of my interventional cardiologists would go for that.

I remember that guy quite vividly. I suppose there might be some PTSD there... I hate it when they coming in talking and die.

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That's very strange, I've had this happen too. Young guy who coded 4 times during the night, restored consciousness within 1-3 minutes every time and would push off the mask when he was awake enough. Very strange to watch the patient push you away when you can't feel pulses and bp monitor is saying 60 over nil

I guess my question is if you measure CO2 in a patient that you are masking, and if so, how?

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Yes, I'll do it when using a BVM. I prefer the nasal cannula in these situations but will use the BVM with the in-line connector if I don't have that. While neither are likely as accurate as in an intubated patient they work well enough and provide useful info on CPR quality and ROSC.

Someday we will all come to the same place where adult arrests get some combination of initial compressions, SGA, oxygen, Narcan, CaCl, and a few shocks with the code called in fifteen minutes if rosc is not achieved. One pathway to rule them all.

Until then, SGA till rosc is fine.

The reality is that for most non vfib arrests CPR is futile care and has more to do with a revenue stream for AHA than anything else.

Because so many providers available at the mothership, will do VL intubation during compressions. I find DL incredibly difficult during compressions. As an aside, more and more of my intubations are becoming VL. I don't want this to turn into a VL vs DL debate, and I was a VL skeptic at first, but I really find it to be so much smoother from both a procedural and team work perspective.

Upon graduation, will likely SGA vs BVM during code and ETT if ROSC. I find that ETT placement frequently distracts from other efforts and as others have cited, pauses in compressions are to be avoided.

I forbid junior residents from attempting crash femoral line during active compressions. Last thing you want is needlestick with large hollow bore needle. No reason not to use I/O.

If coding, no meds. If ROSC will give meds. Usually Etomidate / Succinylcholine unless there is a compelling contraindication. Someone above mentioned Ketamine, which I feel is a somewhat interesting choice given you just obtained ROSC from a possible tachydysrhythmia. Not sure if there's data on this, but I feel like intuitively I wouldn't want to give Ketamine in this situation. Another aside, I find many people in my program being caviler with Ketamine for various indications. It seems to be the sexy drug these days, likely secondary to the blogosphere.

EMS compressions in intubating skills are an issue in my area as well. The one handed 2 inch compressions are irritating, as are the unrecognized esophageal intubations. We had one last week who came in with markedly distended abdomen and EtCO2 on monitor was zero. I had junior resident look with VL who recognized misplacement and re-intubated. Disturbing to think about the poor neurologic outcome that would have been seen if we achieved ROSC on that one. Esophageal intubations are a rare inevitability; unrecognized esophageal intubations however are unacceptable and are a never event in my mind. My future practice will be to check all pre-hospital intubations with VL unless convincing EtCO2 waveform.

I like leaving the automatic compression device in place if they come in with one on. Better than most manual compressions I've seen.

I have also had the person who intermittently regains consciousness with compressions. It's eerie. But hey I guess it means you're doing good compressions! I can't see calling this type of resuscitation while you are still getting this result. Would likely push tPA if even mildly good story for ACS or PE.

Big fan of family witnessed codes. You all know the data to support reduction in PTSD, survivor guilt, etc. Let's them see our maximal efforts etc.

I'll leave the ketamine alone, but sux? Why? Seems like one of the last drugs I would touch.

There are a few very rare reasons I reach for sux in the ED -- but especially in an undifferentiated cardiac arrest with ROSC, I can think of no reason why to choose sux over roc.

Maybe I am missing some indication...if so, please let me know so I can re-consider my practice and teaching.

HH

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???

Lot's of reasons in general to use succinylcholine in the ED.
-Faster onset
-Faster offset

I can think of no reason NOT to use it in this situation, amongst others, unless you have some reason why the patient may be hyperkalemic or one of the other boards question style contraindications - and let's be serious, the 0.5 mg/dl elevation you will get isn't going to make the difference. Seems to me that roc vs sux is a style variation and people use what they are more comfortable with for whatever reason.

If coding, no meds. If ROSC will give meds. Usually Etomidate / Succinylcholine unless there is a compelling contraindication. Someone above mentioned Ketamine, which I feel is a somewhat interesting choice given you just obtained ROSC from a possible tachydysrhythmia. Not sure if there's data on this, but I feel like intuitively I wouldn't want to give Ketamine in this situation. Another aside, I find many people in my program being caviler with Ketamine for various indications. It seems to be the sexy drug these days, likely secondary to the blogosphere.

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I mentioned ketamine, specifically in the rare case of person who is becoming conscious with compressions. It would provide anesthesia / analgesia with minimal hypotension (compared to etomidate, propofol, or enough fentyl/versed to do anything). I am not terribly concerned with ketamine re-precipitating a tachyarrhythmia in a prolonged cardiac arrest. While it certainly can trigger some sinus tachycardia, it is not known to cause all that much Vtach/Vfib... I'd be much more concerned with sux causing further hyperkalemia in an arrest that might have been triggered by hyperkalemia until we know better. Anyway this is a big time niche indication, I've never done this myself but I think I would.

In general, I'm certainly a big etomidate + Sux kinda guy for the great majority of my RSI, but I do think the 'rocket' (Roccuronium + ketamine) has certain advantages with hemodynamics and no potassium shifts.

I'll leave the ketamine alone, but sux? Why? Seems like one of the last drugs I would touch.

There are a few very rare reasons I reach for sux in the ED -- but especially in an undifferentiated cardiac arrest with ROSC, I can think of no reason why to choose sux over roc.

Maybe I am missing some indication...if so, please let me know so I can re-consider my practice and teaching.

HH

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While I agree that in undifferentiated arrest, sux is a poor choice, however, I think the issues with sux are significantly overstated. I like sux when appropriate because of it's quicker onset compared to roc. FOAMed community tends to over exaggerate the issues with sux. The drug is perfectly fine in a patient whose medical history is known.

Lot's of reasons in general to use succinylcholine in the ED.
-Faster onset
-Faster offset

I can think of no reason NOT to use it in this situation, amongst others, unless you have some reason why the patient may be hyperkalemic or one of the other boards question style contraindications - and let's be serious, the 0.5 mg/dl elevation you will get isn't going to make the difference. Seems to me that roc vs sux is a style variation and people use what they are more comfortable with for whatever reason.

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I don't electively intubate people. If they need a tube, they need a tube, and I don't need to be re-paralyzing them if it takes awhile. Having people move when you cut their neck is a serious pucker moment. Onset difference with appropriate dosing is negligible.

While I agree that in undifferentiated arrest, sux is a poor choice, however, I think the issues with sux are significantly overstated. I like sux when appropriate because of it's quicker onset compared to roc. FOAMed community tends to over exaggerate the issues with sux. The drug is perfectly fine in a patient whose medical history is known.

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I agree. But Roc works perfectly well. I often don't intubate people with a well known medical history.

I don't electively intubate people. If they need a tube, they need a tube, and I don't need to be re-paralyzing them if it takes awhile. Having people move when you cut their neck is a serious pucker moment. Onset difference with appropriate dosing is negligible.

I agree. But Roc works perfectly well. I often don't intubate people with a well known medical history.

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Might be my current practice setting, but most of the people I'm intubating are frequent users of the healthcare system and normally have a discharge summary from 1 month prior.

Lot's of reasons in general to use succinylcholine in the ED.
-Faster onset
-Faster offset

I can think of no reason NOT to use it in this situation, amongst others, unless you have some reason why the patient may be hyperkalemic or one of the other boards question style contraindications - and let's be serious, the 0.5 mg/dl elevation you will get isn't going to make the difference. Seems to me that roc vs sux is a style variation and people use what they are more comfortable with for whatever reason.

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The fast offset is what makes me a little ehh about sux. Would rather have plenty of time in cases of difficult airway during compressions. Not thinking about redosing sux is one less thing to worry about.

emrap has had some big talks about roc vs sux recently. it seems to me (west coast uses roc) (east coast uses sux). Ive never had a problem with sux but i dont use it on burns, spastic, or dialysis patients. Either is fine imo.

emrap has had some big talks about roc vs sux recently. it seems to me (west coast uses roc) (east coast uses sux). Ive never had a problem with sux but i dont use it on burns, spastic, or dialysis patients. Either is fine imo.

I use both depending on my RSI situation. Generally use succinylcholine more. If there's rosc I use rocuronium. They are generally sick enough that I don't want to d!ck around with a moving pt while nursing hems and jaws over adjusting sedating meds. It helps avoid that huge bolus of propofol/versed/whatever that then drops the BP that then forces my hand on a bunch of fluids and maybe pressors and/or central. They just need the icu and/or stenting.

Also I'm not seeing many post rosc stemi ekgs these days and cards at my place are generally not keen on caths in post arrest patients. Any of you sending everyone to cath? We are also still using therapeutic hypothermia though lit is mixed now.

I use both depending on my RSI situation. Generally use succinylcholine more. If there's rosc I use rocuronium. They are generally sick enough that I don't want to d!ck around with a moving pt while nursing hems and jaws over adjusting sedating meds. It helps avoid that huge bolus of propofol/versed/whatever that then drops the BP that then forces my hand on a bunch of fluids and maybe pressors and/or central. They just need the icu and/or stenting.

Also I'm not seeing many post rosc stemi ekgs these days and cards at my place are generally not keen on caths in post arrest patients. Any of you sending everyone to cath? We are also still using therapeutic hypothermia though lit is mixed now.

Most arrest patients that arrive in our hospital are intubated pre-hospital by paramedics. The benefits/harm of prehospital intubation can certainly be debated, but that's for another time. The few that aren't intubated were either difficult or had too many other complicating issues and so present with some type of supraglottic device or just a BVM. My approach (as I'm typically the only physician in the room) is to run the code until there's ROSC and at that point establish a definitive airway - if there's no ROSC then I don't feel the need to establish an airway just to pronounce a patient. I was surprised to hear that many residents are taught the need to do so, leading to prolonged pauses in compressions (this is bound to happen even with the best of intentions). It reminded me of my own time in residency and thinking back on it there was always a sense that an airway needed to be established, and there was almost always a pause in compressions to do so. I fail to see the need to establish a definitive airway when a patient's easy to bag and compression effectiveness can be maximized. Others thoughts?

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Agreed. This is my practice as well and appears to be supported by the recent literature.

I use both depending on my RSI situation. Generally use succinylcholine more. If there's rosc I use rocuronium. They are generally sick enough that I don't want to d!ck around with a moving pt while nursing hems and jaws over adjusting sedating meds. It helps avoid that huge bolus of propofol/versed/whatever that then drops the BP that then forces my hand on a bunch of fluids and maybe pressors and/or central. They just need the icu and/or stenting.

Also I'm not seeing many post rosc stemi ekgs these days and cards at my place are generally not keen on caths in post arrest patients. Any of you sending everyone to cath? We are also still using therapeutic hypothermia though lit is mixed now.

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Soooo you want to completely wreck your neuro exam in the post-arrest patient by giving a longer acting paralytic so you don't have to titrate sedation? Then you really have to idea if you should be doing therapeutic hypothermia or not.

As for post arrest cath, that requires the stars to be aligned, the interventionalist has just gotten laid, and the quarter to land on heads.

In the glorious state of Pennsylvania, they publicly report post-cath mortality for the cardiologists, but fail to make a distinction between the outpatient cath for an abnormal stress test and the post-code 80yo who arrested 8 times. Since most of these OHCA patients will do poorly through no fault of the cardiologist, they essentially do nothing now for fear of having their metrics jacked up. Even for those who need it.

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